The Role of Medicare and the Indian Health Service for American Indians and Alaska Natives: Health, Access and Coverage

Relative to the overall U.S. population, American Indians and Alaska Natives face persistent disparities in health status, access to health care, and other socioeconomic disadvantages, including higher rates of poverty. Even with Medicare coverage, American Indians and Alaska Natives who are age 65 and older or who are living with permanent disabilities experience these problems at comparatively high rates.

This report, divided into four sections, examines these disparities and describes the roles of both the Indian Health Service (IHS) and Medicare in providing access to health care for American Indians and Alaska Natives. The first section draws from recent surveys and other data sources to compare health and other socioeconomic indicators among elderly American Indians and Alaska Natives to the overall population age 65 and older. The second section of this report describes the ways that IHS and other sources of coverage (including Medicare, Medicaid, and private insurance) may and may not provide access to health care services for elderly and disabled American Indians and Alaska Natives. The third section explores the intersection of Medicare and the IHS in health service reimbursement, patient cost sharing, and access to care, and then discusses the implications of potential barriers to enrollment in federal or state programs that could assist American Indians and Alaska Natives with out-of-pocket expenses for health care. The report concludes with a discussion of some of the future challenges and opportunities for improving access to care for American Indians and Alaska Natives through Medicare and the IHS.

Main Findings

Section 1 — Key characteristics of American Indians and Alaska Natives who are age 65 and older or living with permanent disabilities

Among the 5.2 million people who self-identify as either partly or solely American Indian or Alaska Native, approximately 450,000 are age 65 or older. Another 200,000 are under age 65 and living with a long-term disability or health condition which qualifies them for Medicare.

American Indians and Alaska Natives live throughout the country, but are generally concentrated in certain geographic areas, with more than one-third of elderly American Indians and Alaska Natives living in four states (California, Oklahoma, Texas and Arizona).

American Indians and Alaska Natives age 65 and older have higher rates of poverty, report poorer health, and report problems accessing care more often compared with the overall U.S. population age 65 and older. Five times as many elderly American Indians and Alaska Natives report that cost issues made them forego medical care, compared with the overall U.S. population age 65 and older.

Section 2 — Roles of the IHS, Medicare, and other sources of coverage for American Indians and Alaska Natives

The IHS, which is subject to annual appropriations, is the principal federal agency that fulfills the U.S. government responsibility to provide health care services to American Indians and Alaska Natives.

The IHS provides and funds health care services—mostly primary care—to eligible American Indians and Alaska Natives through a variety of facilities operated by either the IHS, tribal entities, or Urban Indian Health Programs (collectively referred to as I/T/Us). The majority of these facilities are in rural areas, typically on or near reservations. When service demands exceed available funds, IHS-funded services are prioritized or rationed, especially for contracted services in the purchased/referred care (PRC) program.

Medicare provides health care coverage to people ages 65 and older (if they or their spouse have made payroll tax contributions for 10 or more years) and to younger adults with permanent disabilities or other qualifying health conditions, such as end-stage renal disease. The majority (96%) of American Indians and Alaska Natives age 65 and older have Medicare coverage, according to analysis of the ACS, but other surveys provide lower estimates. Almost one-third (32%) of American Indian and Alaska Natives with Medicare are under age 65—double the proportion found in the overall Medicare population.

Almost one in four (24%) elderly American Indians and Alaska Natives with Medicare also report having Medicaid—with full benefits (full duals), or partial benefits through the Medicare Savings Programs. More than a quarter (28%) of elderly American Indians and Alaska Natives with Medicare have no supplemental coverage, which means they are exposed to Medicare’s out-of-pocket cost sharing requirements unless receiving services from I/T/Us.

Section 3 — The Intersection between the IHS and Medicare in access and coverage for American Indians and Alaska Natives

About a quarter (23%) of all American Indians and Alaska Natives with Medicare also list IHS as a “source of coverage.” This share is proportional to the percent living on reservations or designated land trusts.

In general, I/T/Us may not charge patients any cost sharing, but because IHS is a payer of last resort, its facilities are expected to seek reimbursement from third-party insurers when applicable. In the aggregate, IHS facilities will collect an estimated $217 million in Medicare reimbursements for services they provide to Medicare beneficiaries in 2014. Though a relatively small part of their operating budgets, these collections are important sources of revenue for these providers, given the fiscal pressures inherent in their IHS funding.

Medicaid, Medicare Savings Programs, and Medicare Part D low-income subsidies (LIS) for prescription drug coverage can play an important role in lowering cost sharing for American Indians and Alaska Natives with Medicare. However, researchers have identified several barriers to enrollment in these programs, some of which are unique to American Indians and Alaska Natives, but many of which are shared among vulnerable populations, more generally.

Section 4 — Future opportunities and challenges

Some opportunities exist within Medicare and the IHS to enhance access to care for American Indians and Alaska Natives. For example, new Medicare initiatives to coordinate care in rural areas could lead to better integration of services for American Indians and Alaska Native beneficiaries. Also, I/T/Us, including pharmacies, may have some opportunities to increase their collections from third-party insurers (including Medicare) in future years—given anticipated increases in both the American Indian and Alaska Native population age 65 and older, most of whom will have Medicare, and increasing coverage under the Affordable Care Act (ACA).

This report pulls from a variety of data sources to examine health status, access to care, and coverage among American Indians and Alaska Natives who are age 65 or older or living with permanent disabilities. While this review is comprehensive, data limitations, including small sample sizes and longstanding problems with identifying race in Medicare claims and administrative files, nevertheless, make it difficult to ensure a full understanding of the health and coverage needs of this population.